ACAAI: Asthma Flares Hit Single-Parent Kids Harder

by John Gever John Gever,Senior Editor, MedPage Today
November 08, 2011

Action Points

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Explain that a cohort study found that children admitted to hospital for asthma symptoms were more likely to be readmitted or have an emergency department visit within 12 months if they lived in a single-parent family.

Note that low income was the only significant identified risk factor in a multivariate analysis.

BOSTON -- Repeat hospitalizations or emergency department visits for children initially hospitalized for asthma were significantly more common among those from single-parent homes, although income -- more than other factors related to single-parenthood -- appeared primarily to blame, a researcher said here.

Univariate analysis of a cohort of 522 asthmatic children yielded an odds ratio for readmission or emergency department visit for asthma-related symptoms of 1.5 (95% CI 1.0 to 2.1) associated with single-parent household status, according to Terri Moncrief, MD, of Cincinnati Children's Hospital Medical Center.

But in multivariate analysis that took other factors potentially associated with household status into account, single parenthood per se was no longer a significant factor, whereas household income was associated with risk of rehospitalization and ER visits at an odds ratio of 1.9 (95% CI 1.1 to 3.6), she reported at the American College of Allergy, Asthma, and Immunology annual meeting.

Moncrief told MedPage Today that she believed income was itself a surrogate for still other factors that are the real drivers of poor asthma control in children of single parents. Specifically, she said adherence to maintenance medications (inhaled corticosteroids with or without long-acting beta agonists) is likely to suffer in these children.

The study was a secondary analysis of data collected on children treated at Moncrief's institution, a tertiary care center that treats an estimated 90% of children needing hospitalization or emergency treatment for asthma in eight Cincinnati-area counties.

Interviews were conducted with adult members of households with children admitted to the hospital or treated in its emergency department for asthma exacerbations or bronchodilator-responsive wheezing. Marital status of the household head, the frequency with which children were cared for outside the home (dubbed "mobility"), psychological stress on the so-called K6 scale, and the ratio of children to adults in the home were among the data collected.

The primary outcome measure was a second hospitalization or an ER visit within one year of the index admission.

About half the children included in the analysis were younger than five, and half were African-American. Some 60% had public insurance or were uninsured, and the same proportion were in single-parent households.

Household characteristics were dramatically different for those with single-parent heads versus those with married parents, Moncrief reported.

Single-parent households were far more likely to have income under $15,000 (46% versus 7%), to have mobile caregiving for the child (57% versus 39%), to have higher psychological stressors (mean K6 score 5.6 versus 3.9), and to have more children in the household (mean child:adult ratio of 1.8 versus 1.2) -- all highly significant with P values of less than 0.0001.

But in multivariate logistic regression, only income was significantly associated with repeat hospital care.

Moncrief told MedPage Today that income itself was unlikely to be the real factor underlying the findings. Rather, she said, the daily grind of the single-parent household works against children's medication adherence.

She said the children in the cohort had access to inhalers. But because single parents have so many responsibilities -- working multiple jobs in many cases, juggling various caregivers -- making sure that children use their inhalers on schedule often falls by the wayside, she said.

On the other hand, Gailen Marshall Jr., MD, of the University of Mississippi Medical Center in Jackson, was skeptical of that explanation.

He noted that stress itself is a documented risk factor for asthma exacerbations and suggested it may not be necessary to look any farther than that.

"Prenatal maternal stress has an impact on the child's risk for developing asthma, and this [stress] gets worse and worse with inverse socioeconomics," he said.

Marshall said these stresses also transfer to the child after birth as well.

"Because Mom is working two jobs and is not there ... that parental stress translates to stress on the child, which creates an immune imbalance that is more likely to create disease," he said. "The maternal stress has a direct impact."

He added that if parents' inability to supervise medication adherence is actually the problem, it can be solved by letting school personnel make sure children use their inhalers on schedule.

Moncrief said her group was planning a follow-up study to examine adherence explicitly in their cohort.

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